Esophageal Varices

  1. General information
    1. Dilation of the veins of the esophagus, caused by portal hypertension from resistance to normal venous drainage of the liver into the portal vein
    2. Causes blood to be shunted to the esophagogastric veins, resulting in distension, hypertrophy, and increased fragility.
    3. Caused by portal hypertension, which may be secondary to cirrhosis of the liver (alcohol abuse), swallowing poorly masticated food, increased intra-abdominal pressure
  2. Medical management
    1. Iced normal saline lavage
    2. Transfusions with fresh whole blood
    3. Vitamin K therapy
    4. Sengstaken-Blakemore tube: a three-lumen tube used to control bleeding by applying pressure on the cardiac portion of the stomach and against bleeding esophageal varices. One lumen serves as NG suction, a second lumen is used to inflate the gastric balloon, the third to inflate the esophageal balloon.
    5. Intra-arterial or IV vasopressin
    6. Injection sclerotherapy
    7. Surgery for portal hypertension (decompresses esophageal varices and helps to maintain optimal portal perfusion)
      1. Ligation of esophageal and gastric veins to stop acute bleeding
      2. Portacaval shunt: end-to-side or side-to-side anastomosis of the portal vein to the inferior vena cava
      3. Splenorenal shunt: end-to-side or side-to-side anastomosis of the splenic vein to the left renal vein
      4. Mesocaval shunt: end-to-side or use of a graft to anastomose the inferior vena cava to the side of the superior mesenteric vein
  3. Assessment findings
    1. Anorexia, nausea and vomiting, hematemesis, fatigue, weakness
    2. Splenomegaly, increased splenic dullness, ascites, caput medusae, peripheral edema, bruits
    3. Diagnostic tests
      1. PT prolonged
      2. Hematest of vomitus positive
      3. Serum albumin, RBC, Hgb, and hct decreased
      4. LDH, SGOT (AST), SGPT (ALT), BUN, increased
  4. Nursing interventions
    1. Monitor/provide care for client with Sengstaken-Blakemore tube.
      1. Facilitate placement of the tube: check and lubricate tip and elevate head of bed.
      2. Prevent dislodgment of the tube by placing client in semi-Fowler's position; maintain traction by securing the tube to a piece of sponge or foam rubber placed on the nose.
      3. Keep scissors at bedside at all times.
      4. Monitor respiratory status; assess for signs of distress and if respiratory distress occurs cut the tubing to deflate the balloons and remove tubing immediately.
      5. Label each lumen to avoid confusion; maintain prescribed amount of pressure on esophageal balloon and deflate balloon as ordered to avoid necrosis.
      6. Observe nares for skin breakdown and provide mouth and nasal care every 1-2 hours (encourage client to expectorate secretions, suction gently if unable).
    2. Promote comfort: place client in semi-Fowler's position (if not in shock); provide mouth care.
    3. Monitor for further bleeding and for signs and symptoms of shock; hematest all secretions.
    4. Administer vasopressin as ordered and monitor effects.
    5. Provide routine pre- and post-op care if the client has portasystemic or portacaval shunt.
    6. Provide client teaching and discharge planning concerning
      1. Minimizing esophageal irritation (avoidance of salicylates, alcohol; use of antacids as needed; importance of chewing food thoroughly)
      2. Avoidance of increased abdominal, thoracic, and portal pressure
      3. Recognition and reporting of signs of hemorrhage